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ROI` MRnTAL CHAIN OF CUSTODY <br /> ND ANALYSTS REQUEST DOCUMENT <br /> Mal <br /> Client LAM- r FComp <br /> r(s) i hush Analysis Yes DaSul?Ject to surcharge— 24 hrs <br /> Customer Number <br /> �7 QA/QC report required yes ✓ no <br /> Address zZZO L 0 Hn <br /> Srre ,wtvk 2 r _ Sampler Set up Date Time State Form required yes no <br /> Phone 7z` Mileage Lab number <br /> FAX <br /> I ab Lac SP ❑ STK ❑ VI ❑ 0 <br /> Project name 1i <br /> Contact person Jdz v s <br /> Billing Information(if different from above) <br /> Name. 0 <br /> Address L41+0 �Y�•�o�f- S ��r x <br /> Sf✓V� 203 p Q <br /> V Fri <br /> Phone }}}}}} O <br /> U o. n H a F Gn N <br /> � 7e F C] ,� to u rn <br /> FAXt5 z 4 �^ <br /> Contact personG/ ( 29 �E° C + 6 Fw' i0 A <br /> Purchase ordericontract numberv O <br /> m o z z z <br /> 51 <br /> Lo <br /> Sample cationlDeacription Date Time 3 ^ y <br /> Num Sam !ed Sampled Ey 2~ w ao tit U <br /> Zv <br /> 1 <br /> 1 G -r5 / <br /> - GU r12 <br /> 4 41 <br /> SB-I '40' ✓ 15 S <br /> aw <br /> y ` r - - <br /> k Due Q Iime Relugidcliedby Due Time <br /> Regi Tlme r R"%Vd to- Dale Time <br /> Rd, by' Due ' Time Relioq,dand by tole lime <br /> Received Data Timc Received by DateTime <br /> CORPORATE OFFICE Ae LABORATORY OMC&R LABORATORY F16W OFFICE <br /> PO Boa 272A53=—Suets =S1=113 <br /> 300 Sgaecaaidi R-4 Yndy Califoiela <br /> Sams Paula,CA 72 S+ S1 CA 9521 S Tel (209)734-9473 <br /> To(BOS)659-0910 Tel(209)942-0181 Mobile(209)737 2,399 <br /> FAX (SOS)525-4172 FAX(209)9424)423 FAX(209)734-9435 <br />